Postoperative Pain Outcomes Following Uniportal Versus Multiportal Video-Assisted Thoracoscopic Surgery: A Systematic Review and Meta-Analysis

Fahim Kanani^1*Alaa Zahalka¹Moshe Kamar¹Rijini Nugzar¹Ory Wiesel²Yael Refaely³Anas Salhab¹Mordechai Shimonov¹Diego Gonzalez-Rivas⁴Firas Abu Akar¹

• ¹Edith Wolfson Medical Center, Holon, Israel
• ²Bar-Ilan University The Azrieli Faculty of Medicine, Ramat Gan, Israel
• ³Soroka Medical Center, Be'er Sheva, Israel
• ⁴Universidade da Coruna, A Coruña, Spain

Background: Video-assisted thoracoscopic surgery (VATS) has evolved from multiportal to uniportal approaches, theoretically offering reduced postoperative pain through single intercostal space access. However, inconsistent surgical definitions and mixed evidence have limited clinical guidance. Objectives: To systematically evaluate postoperative pain outcomes between true uniportal VATS (strictly defined by ESTS 2019 criteria) and multiportal VATS for lung resections. Methods: We searched five databases from January 2000 to January 2025 for comparative studies of uniportal versus multiportal VATS reporting pain outcomes. True uniportal VATS required a single intercostal incision (2.5-5cm) with all instruments through one port. Meta-analyses were excluded to prevent data duplication. Primary outcome was 24-hour pain intensity. Random-effects meta-analysis calculated standardized mean differences (SMD) with 95% confidence intervals. Risk of bias was assessed using ROB 2 (RCTs) and ROBINS-I (observational studies). Results: Nineteen studies (6 RCTs, 13 observational) comprising 2,544 patients (1,156 uniportal, 1,388 multiportal) met inclusion criteria. Uniportal VATS significantly reduced pain at 24 hours (SMD -0.98, 95% CI -1.12 to -0.84, p<0.0001), equating to 2.5 points on a 10-point scale. Benefits persisted at 48 hours (SMD -0.80) and 7 days (SMD -0.58). Opioid consumption decreased by 10.6mg morphine equivalents (95% CI -14.8 to -6.4). Heterogeneity was moderate (I²=63.6%). Studies using standardized analgesia protocols showed larger effects (SMD -1.05) with lower heterogeneity (I²=58.4%). Meta-regression identified decreasing effect sizes over time (β=0.05 per year, p=0.024). Sensitivity analyses confirmed robustness, with all iterations maintaining statistical significance. Conclusions: True uniportal VATS provides clinically meaningful reductions in postoperative pain compared to multiportal approaches when applying strict anatomical criteria. Benefits are enhanced with standardized perioperative analgesia protocols. Implementation should consider local expertise and the observed heterogeneity in treatment effects. Registration: Not prospectively registered; PRISMA 2020 guidelines followed.